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TD InsuranceInstructions for completing the claim package forCredit Protection Critical Illness InsuranceLife-Threatening CancerThis insurance benefit is underwritten by The Canada Life Assurance Company ("Canada Life"), and TD LifeInsurance Company ("TD Life") is the authorized administrator. TD Life will be managing this claim on behalf ofCanada Life.The Credit Protection Critical Illness Insurance - Life Threatening Cancer Claim Package contains two parts:Ŷ Part A: Claimant's Statement for Credit Protection Critical Illness Insurance - Life Threatening Cancer.Ŷ Part B: Attending Physician's Statement of Critical Illness Insurance - Life Threatening Cancer.Note:ŶŶŶŶRequest for medical records excludes any genetic test results. Please do not provide any genetic test resultsPlease print all information using a pen.Initial all corrections/changes, including any changes you make with correction fluid (liquid paper).Completion of all parts is required and any missing information may result in the delay of the processing ofyour claim.Ŷ Checkboxes are provided below to assist you in completing the claim package.Ŷ Within 10 business days of receiving your claim package, a claims analyst will send you a confirmation ofreceipt in writing.Ŷ If you have any questions, please contact the TD Life Claims Department at 1-888-983-7070.Instructions for ClaimantCheck if completedPlease complete Part A - Claimant's Statement for Credit Protection Critical Illness Insurance - Life Threatening Cancer.Ŷ Be sure to print your first and last name, date and sign all entries and include your telephone number.Ŷ If you are not the Insured, you must be an authorized representative of the Insured.Please ensure that both sections of Part B - Attending Physician's Statement of Critical Illness Insurance - LifeThreatening Cancer are completed.Section 1 - Patient's Authorization - the Insured/patient's signature and date are required.Section 2 - Attending Physician's Statement must be completed and signed by a licensed medical practitioner .Note: Part B of this document can be detached and provided to the Attending Physician to complete and sendseparately to TD Life Insurance.Retain a photocopy of the completed claim package for your records.Return the original forms to:TD InsuranceClaims DepartmentP.O. Box 1TD CentreToronto, Ontario M5K 1A2ORYou may bring the original forms back to your TD Canada Trust branch in a sealed envelope to be sent to TD Life.512158 (0419)
PART A - Claimant's Statement for Credit Protection Critical Illness Insurance Life Threatening CancerStatement of Claim (Completed by Claimant)The completion of the below product details is mandatory in order to process this claim. If you do not have the product details, pleasecontact your TD Canada Trust branch before submitting the claim forms.Product:MortgageLine of CreditBranch/Transit Number:Mortgage/Line of Credit Number:Please provide details of any other credit insured mortgages, lines of credit or loans held by the Insured at TD Canada Trust.Section 1 - Claimant's StatementName of Insured:Address of Insured:Insured Date of Birth:If you are not the Insured, please complete the Claimant details below and confirm what is your relationship to the Insured?.Name of the Claimant: (Last Name)Address:(First Name and Initial)(Number)(Street)(City)Date of Birth:(Province)(Postal Code)(Month, Day, Year)Telephone Number:Alternate Telephone Number:1. Claim and related detailsa) Please provide details of your Critical Illness.b) On what date was your condition diagnosed or surgery performed?c) (i)(ii)On what date did symptoms first commence?Please describe these symptoms.d) On what date did you first consult a medical practitioner in connection with your illness?e) Have you undergone any tests or investigations related to the diagnosis?YesNoIf yes, please provide details and dates.f) Have you previously suffered from, or received treatment for, a similar or related condition?YesNoIf yes, please give details including dates.512158 (0419)
2.Medical Consultationsa) (i)Please provide the name, address and phone number of your personal physician.(ii)How long has he/she been your personal physician?b) Please list the names, addresses and phone numbers of physicians seen in the past 5 years, other than those listed in (a) (i) above.c) List the names and locations of all hospitals and/or institutions where you were treated in the past 5 years, (Include admission anddischarge dates).d) Please provide the names, addresses and phone numbers of any other physicians or specialists who have been consulted in connectionwith your illness.e) What treatment have you received and are you currently receiving in connection with your condition?Type of treatmentInstitution/PhysicianFromDatesTo3. Generala) Have any of your immediate family (mother, father, brother(s), sister(s)) had cancer, tumour,heart disease, diabetes, kidney disease, stroke, or suffered from a similar or related condition?YesNob) If yes, list relationship, condition, age at which illness was first diagnosed, and date of diagnosis.RelationshipConditionAge at which illness Date of Diagnosis(Month, Day, Year)was first diagnosedc) Please provide any further information which you think might be helpful in support of your claim.This claim form can be used for otherwise valid claims under discontinued policies.512158 (0419)
Critical Illness Insurance Claim AuthorizationInsurer:The Canada Life Assurance Company ("Canada Life")Claimant's Authorization and Declaration:Ŷ I declare that all the statements made in this claim form are accurate, true and complete. I understand that making false,misleading or incomplete statements may cause not only the claim to be denied, but insurance coverage to be rescinded by theInsurer.Ŷ I hereby authorize and request any physician, hospital, clinic, individual, law enforcement or government organization,insurance company, worker's compensation body, current or former employer, or other entity that has any personal and medicalrecords, information or knowledge in regard to the Insured (if other than the Claimant), to release and provide full details(including furnishing copies) of all available personal and medical information records and knowledge, including prior medicalhistory, toxicological or pathological findings which they may possess to the above noted Insurer in regard to this claim, its reinsurers or their respective agents. This information is to be used in the evaluation of an insurance claim and for purposesrelating to such claim.Ŷ I also authorize the Insurer, its reinsurers and its respective agents to exchange and/or transmit information concerning this claimto the organizations listed above as is necessary to evaluate this claim. This consent shall be valid during the continuation ofsuch claim.Ŷ I further authorize the Insurer or its administrator to release information relating to this claim (however, not including medicalinformation) to The Toronto-Dominion Bank to allow the bank to manage the credit facility related to this insurance.If I am not the Insured:Ŷ In providing this authorization to collect personal information about the Insured relating to this claim, I the undersigned dohereby certify that I have appropriate permission from the Insured to authorize the collection, use and disclosure of theirpersonal information as authorized above and that the Insurer and its agents and reinsurers may rely and act upon myauthorization.ClaimantClaimant's Signature(Print Last name, First name and initial)Date(Month, Day, Year)A photocopy/fax of this authorization is as valid as the original.512158 (0419)
PART B - Attending Physician's Statement for Critical Illness - Life Threatening CancerSection 1 - Patient's AuthorizationPatient's Name (Please Print):Date of Birth:(Month, Day, Year)I hereby authorize the release of any information requested in respect of this claim, to my Insurer, The Canada Life AssuranceCompany and its authorized claims administrator, TD Life Insurance Company.I understand that I can revoke this consent at any time but that without it my claim may not be assessed.Date:(Month, Day, Year)Signature of Patient:Section 2 - Attending Physician's Statement (Completed by Physician)This form has been specifically designed with the Physician in mind. By being comprehensive, it will hopefully reduce the physician'sadministrative workload. Please complete the sections relating to your patient and strike out non-applicable areas. In order to help theclaimant, sufficient details of family and medical history, investigation, findings and treatment are essential.Note: Before you submit the form, please ensure you complete the Declaration section, including your signature.The patient is responsible for securing this form and any charge which may be made for its completion.Request for medical records excludes any genetic test results. Please do not provide any genetic test resultsThe above named is insured with The Canada Life Assurance Company against the happening of certain contingent events associatedwith his/her health. A claim has been submitted in connection with Cancer (life-threatening) and, to enable the assessment of theclaim, we would be grateful for your cooperation on the completion of this form.1.a) On what date did your patient first have symptoms?Please list these symptoms:b) On what date did your patient first consult you for this condition?c) How long has the Insured been your patient?2.a) Please provide the date this cancer was diagnosed.b) Please provide the name of the doctor who diagnosed this cancer (if other than yourself).c) On what date was the patient advised of the diagnosis?3.Please provide a copy of the pathology report giving the following details:a) Type of tumourb) Site of tumourc) Histology and staging512158 (0419)
4.Please provide the names and addresses of other physicians consulted or hospitals attended by your patient for this cancer.5.Has your patient previously suffered from cancer or any other conditions that may have contributed tohis/her illness?If "Yes", please provide dates and details.6.Is your patient HIV positive?YesNo7.Is there any immediate family history of cancer, tumour, heart disease, stroke, or suffered from a similar orrelated condition?If yes, list condition, date of diagnosis and relationship to the patient.YesNoRelationshipYesConditionNoDate of diagnosis(Month, Day, Year)8.Please provide details of your patient's tobacco or nicotine use including amount per day and date last used.9.Please provide copies of clinical notes and hospital reports for our Medical Director's review.Notice to Physician:The information in this statement will be kept in a life, health, or disability benefits file with the Insurer or plan administrator andmight be accessible by the patient or third parties to whom access has been granted or those authorized by law. I understand that Ican revoke this consent at any time but that without it my patient's claim may not be assessed. By providing the information Iconsent to such unedited release of any information contained herein.Attach any specialist report, if available.You may mail or fax this form to the Administrator below:TD InsuranceClaims DepartmentP.O. Box 1TD CentreToronto, Ontario M5K 1A2Tel: 1-888-983-7070Fax: 416-308-1223 / 1-877-838-2163Declaration: These statements are true and complete to the best of my knowledge and belief.Physician's Signature:Date:(Month, Day, Year)Specialty:Print Name:Telephone Number:Address:Fax Number:Thank you for taking the time to complete this form.512158 (0419)
This insurance benefit is underwritten by The Canada Life Assurance Company ("Canada Life"), and TD Life Insurance Company ("TD Life") is the authorized administrator. TD Life will be managing this claim on behalf of Canada Life. The Credit Protection Critical Illness Insurance - Life Threatening Cancer Claim Package contains two parts:
